Provider Demographics
NPI:1033174024
Name:HARTVILLE INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:HARTVILLE INTERNAL MEDICINE PA
Other - Org Name:EAST CANTON MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMIN
Authorized Official - Middle Name:YOUSSEF
Authorized Official - Last Name:KHALIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-877-9388
Mailing Address - Street 1:113 CEDAR ST S
Mailing Address - Street 2:PO BOX 30170
Mailing Address - City:EAST CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44730-1305
Mailing Address - Country:US
Mailing Address - Phone:330-488-0767
Mailing Address - Fax:330-488-2907
Practice Address - Street 1:113 CEDAR ST S
Practice Address - Street 2:
Practice Address - City:EAST CANTON
Practice Address - State:OH
Practice Address - Zip Code:44730-1305
Practice Address - Country:US
Practice Address - Phone:330-488-0767
Practice Address - Fax:330-488-2907
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HARTVILLE INTERNAL MEDICINE PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-20
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2621201Medicaid
OHHA9318533Medicare PIN
OH2621201Medicaid